Early Pregnancy Flashcards
What is the action of hCG?
Stimulates corpus luteum to produce progesterone, which is necessary to maintain pregnancy until 8 weeks. At this point, the placenta takes over production of hCG
How early can hCG be detected?
Several days before the scheduled period
What is a biochemical pregnancy?
Failure of implantation. There is an initial positive hCG that then becomes negative.
How soon can pregnancy be detected on USS? What is the order + timings of when things appear?
At 5 weeks (after LMP), the gestational sac can be seen within the uterus. The circular yolk sac is then visible, followed by the embryo at 5.5 weeks.
Define a miscarriage
Pregnancy that ends spontaneously before 24 weeks
Name the types of miscarriage and describe (bleeding, os, FH, etc)
Threatened: bleeding, os closed, FH present
Inevitable: bleeding, os open, no FH
Incomplete: bleeding, os open, RPOC visible
Complete: no bleeding, os closed, empty uterus
Missed: no bleeding, os closed, no FH
A 25 year old G1P0 is seen in EPAU with PV bleeding and mild abdominal crampy pain. She is 9 weeks pregnant. The external os is open. On TVUSS, there is a visible fetus with CRL 24mm with no heartbeat. What is the likely diagnosis?
This woman has had a miscarriage. Bleeding, os open, no FH. Because the CRL is >7mm without a fetal heartbeat, you can confidently say this is a miscarriage.
How common are miscarriages?
Very common. About 10-20% of pregnancies end in miscarriage.
A pregnant woman 10/40 presents with PV bleeding. What are 3-4 differential diagnoses, and what would you want to know from history/examination/Ix to rule these in or out?
Miscarriage: pain, state of the os, TVUSS for FH
Ectropion: PCB, examine cervix
Infection: discharge, pain during sex, swabs
Cervical cancers: last smear, examine cervix
Name some causes of miscarriage.
Chromosomal abnormalities Illness Uterine abnormality Infections Drugs/chemicals
A 30 year old pregnant woman comes to A&E with PV bleeding. She is 9 weeks pregnant. The bleeding started a few hours ago, and is quite heavy. She has had to use 2 pads and it is still ongoing. Describe your management of this case.
If unstable, A-E approach Take a full history Abdo and pelvic exam TVUSS Consider further management as needed
Describe the management of miscarriage and the indications.
3 different types:
- Expectant: wait 7-14 days for bleeding to resolve. Usually if early loss, inevitable + incomplete.
- Medical: misoprostol 800ug intravaginal. For missed + incomplete as alternative to or next step after expectant management.
- Surgical: manual vacuum aspiration with misoprostol to ripen cervix. If larger fetus (greater risk of heavy bleeding with medical Mx), failure of medical management, excessive bleeding, unstable, infected RPOC, woman’s preference.
A 30 year old woman attends A&E with PV bleeding. She is 7 weeks pregnant. On examination she is stable, the external os is open. On TVUSS, a fetus is seen with CRL of 6.5mm and there is no FH. What management would you advise?
This is likely to be a miscarriage. As the CRL is <7mm, the most appropriate management would be expectant until a repeat USS in 7 days confirms the diagnosis. If she is still bleeding at that time and a miscarriage is diagnosed, she would then have a choice between expectant, medical or surgical management, unless there were any contraindications to any of the above options. Whichever she chooses, she will need to do a hCG test at 3 weeks to check that the miscarriage is complete.
A 28 year old woman comes to A&E with continuous PV bleeding. She was diagnosed with a miscarriage 2 weeks ago and had opted for expectant management at the time. What would you do now?
- A-E if unstable
- History, can ask for symptoms of infection
- Abdo exam (checking for tenderness)
- Urine pregnancy test
- Bloods
- Refer to EPAU
In which cases are you required to rescan in 7-14 days to diagnose miscarriage?
- If the mean sac diameter is <25mm (with or without yolk sac). 14 days
- If the mean sac diameter is 25+mm with a yolk sac but no fetal pole. 7 days.
- If the CRL <7mm (and no FH). 7 days.
What would you need to tell a woman who has opted for expectant management of miscarriage?
- Explain what it is and most women will need no further treatment
- Explain risks of infection, pain, bleeding (no greater than other types of management)
- Provide written info
- Safety net
- If bleeding stops within 2 weeks, take a hCG test after 3 weeks and come back if still positive
- If bleeding continues or increases at 2 weeks, come back for another check up
What would you tell a patient who is having medical management of miscarriage?
- Explain what it involves
- Explain side effects of pain, n+v, bleeding. Offer pain relief and antiemetics
- Should contact healthcare professional if no bleeding in 24 hours (missed)
- Take a pregnancy test after 3 weeks and return if positive
- Provide written info
- Safety net (infection, severe pain or very heavy bleeding)
What would you tell a woman who is having a surgical management of miscarriage?
- Explain what is involved and all of the options
- Explain complications: pain, bleeding, rarely infection (the same with any option), damage eg perforation (uncommon), cervical incompetence (rare), and risk of scarring of the endometrium (uncommon)
- Need to give anti-D if RhD negative
- Prophylactic antibiotics
Define recurrent miscarriage
Recurrent miscarriage is defined as 3+ consecutive pregnancy losses
What are some causes of recurrent miscarriage?
Infection, APS, older age, chromosomal abnormalities, uterine structural anomalies, obesity
What are some investigations for recurrent miscarriage?
APS antibodies, imaging of the uterus, cytogenetic analysis and karyotyping
A 25 year old comes in with PV bleeding at 8 weeks. Os closed, FH present. She wants to know how likely she is to have a miscarriage and if there’s anything she can do to prevent it. What would say?
25% will miscarry.
Bed rest, etc is not proven to reduce the risk.
A 24 year old comes to A&E 7 days after attending EPAU where she was told she was likely having a miscarriage and to return in 7 days for a repeat scan. She has ongoing bleeding, and has had a fever and offensive discharge for the past 2 days. What is the likely diagnosis and what is your management?
This woman may have infected RPOC or endometritis. She should be given antibiotics after swabs for MC&S and have surgical removal of RPOC.
Define ectopic pregnancy
Extrauterine pregnancy
